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Cross-Sectional - Breast Feeding and Obesity

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                        Breast feeding and obesity: cross sectional study
                        Rüdiger von Kries, Berthold Koletzko, Thorsten Sauerwald, Erika von Mutius,
                        Dietmar Barnert, Veit Grunert and Hubertus von Voss

                        BMJ 1999;319;147-150


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Breast feeding and obesity: cross sectional study
Rüdiger von Kries, Berthold Koletzko, Thorsten Sauerwald, Erika von Mutius, Dietmar Barnert,
Veit Grunert, Hubertus von Voss



Abstract                                                    children and adolescents, and there is a continuing           Institute for Social
                                                                                                                          Paediatrics and
                                                            increase in their prevalence.1 Overweight children have       Adolescent
Objective To assess the impact of breast feeding on         a high risk of being overweight in adulthood 2–4 and          Medicine, Ludwig
the risk of obesity and risk of being overweight in         therefore are also at risk from the associated health         Maximilians
children at the time of entry to school.                    complications such as hypertension and coronary
                                                                                                                          University,
                                                                                                                          Heiglhofstr 63,
Design Cross sectional survey                               heart disease.5 Since therapeutic interventions aimed         D-81377 Munich,
Setting Bavaria, southern Germany.                          at encouraging weight loss in obese children are costly       Germany
Methods Routine data were collected on the height           and have long term success rates that are less than sat-      Rüdiger von Kries,
and weight of 134 577 children participating in the                                                                       professor of
                                                            isfactory,6 the identification of strategies for the          paediatrics
obligatory health examination at the time of school         effective prevention of obesity is particularly attractive.   Dietmar Barnert,
entry in Bavaria. In a subsample of 13 345 children,            Simple strategies without potential side effects are      statistician
early feeding, diet, and lifestyle factors were assessed    the most appealing. Breast feeding would fulfil these         Veit Grunert,
using responses to a questionnaire completed by                                                                           statistician
                                                            criteria. However, the impact of breast feeding on            Hubertus von Voss,
parents.                                                    obesity has only been studied in comparatively small          professor of
Subjects 9357 children aged 5 and 6 who had                 cohorts.7–9 These small studies failed to find a              paediatrics
German nationality.                                         protective effect possibly due to a lack of statistical       Dr von
Main outcome measures Being overweight was                  power, whereas a protective effect has been reported in
                                                                                                                          Haunersches
                                                                                                                          Kinderspital,
defined as having a body mass index above the 90th          a Canadian cross sectional study of 1320 adolescents          Ludwig
centile and obesity was defined as body mass index          born in the late 1960s.10 The rates of breast feeding         Maximilians
above the 97th centile of all enrolled German               were low in Canada at that time, and lifestyles in indus-
                                                                                                                          University,
                                                                                                                          Lindwurmstr 4,
children. Exclusive breast feeding was defined as the       trialised countries have changed considerably over the        D-80337 Munich
child being fed no food other than breast milk.             past three decades. We have therefore studied the             Berthold Koletzko,
Results The prevalence of obesity in children who           impact of breast feeding on the prevalence of being
                                                                                                                          professor of
                                                                                                                          paediatrics
had never been breast fed was 4.5% as compared with         overweight or obese in children born in the early             Thorsten
2.8% in breastfed children. A clear dose-response           1990s.                                                        Sauerwald,
effect was identified for the duration of breast feeding                                                                  senior house officer
on the prevalence of obesity: the prevalence was 3.8%                                                                     Erika von Mutius,
                                                                                                                          reader in paediatrics
for 2 months of exclusive breast feeding, 2.3% for 3-5      Subjects and methods
months, 1.7% for 6-12 months, and 0.8% for more                                                                           Correspondence to:
than 12 months. Similar relations were found with the       Study population and data sources                             R von Kries
                                                            The 1997 obligatory health examination before school          ag.epi@lrz.
prevalence of being overweight. The protective effect                                                                     uni-muenchen.de
of breast feeding was not attributable to differences in    entry evaluated 134 577 children in Bavaria, southern
social class or lifestyle. After adjusting for potential    Germany. At the examination, the parents of 13 345            BMJ 1999;319:147–50

confounding factors, breast feeding remained a              children seen in two rural regions were asked to com-
significant protective factor against the development       plete a questionnaire about risk factors for atopic
of obesity (odds ratio 0.75, 95% CI 0.57 to 0.98) and       diseases.11 Data collected by this questionnaire were
being overweight (0.79, 0.68 to 0.93).                      linked with the data from the school health
Conclusions In industrialised countries promoting           examination. Our analysis was confined to children
prolonged breast feeding may help decrease the              aged 5 and 6 who had German nationality.
prevalence of obesity in childhood. Since obese                 The children’s height and weight were measured as
children have a high risk of becoming obese adults,         part of the routine examination. Body mass index was
such preventive measures may eventually result in a         calculated as weight (kg)/(height (m)2). The age specific
reduction in the prevalence of cardiovascular diseases      and sex specific distribution of the body mass index
and other diseases related to obesity.                      among all children with German nationality in Bavaria,
                                                            which had been investigated during the 1997 school
                                                            health examination, was used as the reference for
                                                            being overweight (defined as body mass index above
Introduction                                                the 90th centile) or obese (defined as body mass index
In industrialised countries obesity and being over-         above the 97th centile) because these centiles were
weight are the most frequent nutritional disorders in       higher than other European reference values.12

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                                                                                              calculations were carried out with the SAS software
         Table 1 Duration of breast feeding and prevalence (95%
                                                                                              package, version 6.12.
         confidence interval) of being overweight (body mass index above
         the 90th centile) or obese (body mass index above the 97th
         centile) among 5 and 6 year olds living in rural Bavaria
                                                                                              Results
                                                           Prevalence (%) of:
                                                                                              The overall response rate to the questionnaire was
         Duration of breast feeding             Being overweight        Being obese
                                                                                              76.7% (10 240/13 345) Parents whose children had
         Never breast fed (n=4022)              12.6 (12.4 to 12.9)    4.5 (4.4 to 4.6)
         Ever breast fed (n=5184*)               9.2 (9.0 to 9.3)      2.8 (2.7 to 2.8)
                                                                                              been examined before 1 February did not receive ques-
         Exclusively breast fed for:                                                          tionnaires and were classed as non-responders. We
           <2 months (n=2084)                   11.1 (10.6 to 11.6)    3.8 (3.6 to 4.0)       could not differentiate between true non-responders
           3-5 months (n=2052)                   8.4 (8.1 to 8.8)      2.3 (2.2 to 2.4)       and children whose parents had not been given
           6-12 months (n=863)                   6.8 (6.1 to 7.6)      1.7 (1.6 to 1.9)       questionnaires so both were included as non-
           >12 months (n=121)                    5.0 (1.1 to 8.8)      0.8 (0.2 to 1.5)       responders for calculations of well baby visits and
         *Duration of breast feeding was not reported for 64 children who had ever            immunisations because similar results had been
         been breast fed.                                                                     obtained when these calculations were confined to those
                                                                                              offices where all parents had received questionnaires.
         Questionnaire                                                                             A total of 9357 questionnaires were completed for 5
         Parents were asked: “Was your child breast fed?” If they                             and 6 year old German children. Information on breast
         answered yes they were then asked: “For how long was                                 feeding and its duration was available for 9206 children.
         your child exclusively breast fed: (a) 2 months or less,                             A total of 4022 children had never been breast fed and
         (b) 3 to 5 months, (c) 6 to 12 months or (d) more than                               5184 had ever been breast fed. The duration of breast
         a year?” Exclusive breast feeding was defined as the                                 feeding was not reported for 64 children.
         child being fed no food other than breast milk.                                           Responders were more likely than non-responders
             To assess potential confounders additional questions                             to have attended all well baby visits (70.6% (6524/
         were asked about the number of older siblings the child                              9238) v 64% (4511/7044)) and to have had their chil-
         had and the parents’ ages, the child’s health (for                                   dren vaccinated against measles and Haemophilus
         example, was the child born prematurely or at low birth                              influenzae type b (72.3% (6764/9357) v 64%
         weight?), early feeding (for example, when solid foods                               (4596/7178)), but mean body mass index and the 90th
         were introduced), and the actual frequency of eating                                 and 97th centiles for body mass index were similar
         selected foods. The highest level of education attained by                           between the groups (mean 15.36 v 15.34; 90th centile
         either parent was used as a marker for social class.                                 17.70 v 17.75; and 97th centile 20.12 v 20.07).
                                                                                                   There was a clear dose dependent effect of the
         Statistical analyses                                                                 duration of breast feeding on the prevalence of being
         The prevalences of overweight and obese children                                     overweight or obese in children at the time of entry to
         were calculated according to the duration of breast                                  school (table 1). Similar effects of the duration of breast
         feeding. The appropriate 2 tests were used to compare                                feeding on the prevalence of being overweight or
         several items in breastfed and non-breastfed children                                obese were observed when different definitions of
         and their association with the child being overweight                                being overweight or obese were used (that is, above the
         or obese. Logistic regression models were used to                                    90th centile or above the 97th centile for weight; above
         assess the impact of variables that were significantly                               110% or above 120% of the median weight for height
         associated (P < 0.05) with both breast feeding and                                   categories in the total population (data not shown)).
         being overweight or obese. Confounding was assumed                                        Several indicators of the family’s lifestyle and make
         to have occurred if the odds ratio changed by >10%.                                  up (for example, whether the child had his or her own
         Confounders and independent risk factors were                                        bedroom, the amount of time spent playing outside in
         included in the final logistic regression model. All                                 winter and summer, whether the mother smoked during


         Table 2 Prevalence of independent risk factors associated with breast feeding and being overweight or obese in 5 and 6 year old
         children in rural Bavaria
                                                                                     Prevalence (%)                              Odds ratio (90% CI) for:
                                                                       Non-breast fed        Breast fed children
                                                                      children (n=4022)           (n=5184)            Being overweight                    Being obese
         High level of parental education (>10 years)*                      41.4                      66.7           0.77 (0.67 to 0.89)             0.62 (0.49 to 0.79)
         Maternal smoking during pregnancy                                  12.8                       4.2           1.51 (1.20 to 1.89)             1.82 (1.28 to 2.58)
         Prematurity                                                        13.8                       9.0           0.78 (0.62 to 0.98)             0.69 (0.46 to 1.03)
         Birth weight <2500 g                                               10.4                       6.6           0.69 (0.48 to 0.84)             0.78 (0.54 to 1.10)
         Own bedroom                                                        45.6                      54.4           1.19 (1.03 to 1.37)             1.22 (0.96 to 1.56)
         Consumes margarine >3 times/week                                   35.3                      32.4           1.22 (1.05 to 1.41)             1.21 (0.94 to 1.56)
         Consumes butter >3 times/week                                      60.5                      69.2           0.73 (0.63 to 0.83)             0.70 (0.56 to 0.88)
         Consumes full fat milk >3 times/week                               50.8                      59.6           0.69 (0.60 to 0.80)             0.54 (0.42 to 0.68)
         Consumes low fat milk >3 times/week                                31.9                      28.8           1.72 (1.49 to 1.99)             1.77 (1.38 to 2.25)
         Consumes full fat quark or yogurt >3 times/week                    28.8                      36.1           0.66 (0.56 to 0.78)             0.52 (0.38 to 0.70)
         Consumes low fat quark or yogurt >3 times/week                     25.9                      23.8           1.42 (1.22 to 1.66)             1.32 (1.02 to 1.71)
         Consumes whipped cream >1 time/week                                18.6                      24.7           0.65 (0.54 to 0.79)             0.58 (0.41 to 0.81)
         Consumes breakfast cereals >3 times/week                           25.6%                     35.3           0.80 (0.68 to 0.93)             0.76 (0.58 to 0.99)
         Consumes sweet desserts >3 times/week                              54.4%                     57.8           0.84 (0.74 to 0.97)             0.82 (0.66 to 1.03)
         *This variable changed the odds ratio for breast feeding and being overweight or obese by at least 10%, so confounding was assumed to have occurred.



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Table 3 Odds ratios for independent risk factors associated with
                                                                                   Discussion
being overweight or obese in the final logistic regression model                   Epidemiological evidence for reduced risk
for 9206 5 and 6 year old children in rural Bavaria                                To our knowledge this is the largest epidemiological
                                            Odds ratio (90% CI) for:               study on the impact of breast feeding on the risk of
                                   Being overweight           Being obese          school age children being overweight or obese. The
Breast feeding                     0.79 (0.68 to 0.93)     0.75 (0.57 to 0.98)     most remarkable finding is a consistent, protective, and
High level of parental education   0.81 (0.70 to 0.95)     0.75 (0.58 to 0.98)     dose dependent effect of breast feeding on different
  (>10 years)*
                                                                                   definitions of obesity or being overweight. Some relevant
Maternal smoking during            1.52 (1.81 to 1.95)     1.85 (1.26 to 2.71)
  pregnancy                                                                        questions, however, were not asked in our questionnaire
Birth weight <2500 g               0.68 (0.53 to 0.88)     0.81 (0.54 to 1.20)     because it had been designed originally to identify atopy.
Own bedroom                        1.24 (1.05 to 1.46)     1.20 (0.91 to 1.59)     The impact of breast feeding on body mass increase
Consumes butter                    0.72 (0.62 to 0.84)     0.69 (0.54 to 0.90)     (“catch up growth”) in low birthweight infants, which is
  >3 times/week                                                                    associated with an additional risk of coronary heart dis-
*This variable changed the odds ratio for breast feeding and being overweight      ease,13 could therefore not be analysed. A positive family
or obese by at least 10%, so confounding was assumed to have occurred.
                                                                                   history of being overweight is an important indicator of
                                                                                   the genetic risk for obesity and being overweight,9 10
pregnancy, the number of older siblings, and the age of                            although it is not a confounder of the association
the parents), early feeding habits, and the frequency of                           between breast feeding and obesity or being overweight
the consumption of several products in the child’s diet                            as found in a previous study.10
differed significantly between children who had been                                   Breast feeding was associated with family make up
breast fed and those who had not. The prevalence of                                and lifestyle, premature birth, low birth weight, and
variables which were also significantly associated with a                          early and current diet. There was an inverse relation
child being overweight or obese and which were                                     between the consumption of butter and margarine and
independent risk factors in a logistic regression model                            consumption of low fat and full fat dairy products. The
with breast feeding is shown in table 2.                                           inverse relation between the actual consumption of full
    Higher levels of parental education (>10 years),                               fat dairy products and obesity or being overweight
premature birth, and low birth weight were inversely                               probably reflects avoidance of these products by
associated with being overweight or obese, whereas                                 children who are overweight. Because of these strong
maternal smoking during pregnancy and the child                                    relations and the apparent reverse causation with
having his or her own bedroom were positively corre-                               regard to full fat dairy products, only low birth weight
lated. Full fat milk products and sweet desserts were                              and the consumption of butter were added to the final
less frequently consumed by overweight children, and                               logistic regression model.
the consumption of low fat milk products was higher.                                   The protective effects of a higher level of parental
Overweight children also ate less butter and breakfast                             education and low birth weight accord with the results of
cereals than children who were not overweight.                                     other studies.9 10 13 Family income or social class might be
    The level of parental education was the only factor                            better indicators of socioeconomic status. Unfortunately,
that accounted for a shift of the odds ratio towards                               in Germany there is no accepted equivalent to the Brit-
unity by at least 10% which related breast feeding to                              ish categories of social class, and respondents to written
being overweight or obese. In the final logistic                                   questionnaires are reluctant to report income.
regression, which estimated the influence of breast                                    A similar dose dependent reduction in the risk of
feeding on the dependent variable of being overweight                              being overweight or obese as associated with breast
or being obese, the independent risk factors for mater-                            feeding was observed in Canadian adolescents born in
nal smoking, low birth weight, own bedroom, and                                    the 1960s.10 Only 18.5% of these children had been
frequent consumption of butter were included in addi-                              breast fed exclusively as compared with 56% of those
tion to the confounding variable of higher level of                                born in Bavaria in the 1990s; this suggests that mothers
parental education (table 3).                                                      with different sociodemographic characteristics have
    Crude and adjusted odds ratios for the dose                                    chosen to breast feed their children in Bavaria now. If
dependent impact of breast feeding on being                                        this dose dependent protective effect had been caused
overweight or obese are shown in table 4. In children                              by lifestyle factors associated with breast feeding, similar
who had been breast fed for at least 6 months or more                              confounding factors should have been operative during
the risks of being overweight or obese were reduced by                             different times in different societies. These factors would
 > 30 % and > 40%, respectively.                                                   also have to be closely related to the duration of breast


Table 4 Crude and adjusted odds ratios (95% confidence intervals) of the dose dependent impact of breast feeding on being
overweight or obese in children aged 5 or 6 in rural Bavaria
                                                                   Being overweight                                              Being obese
                                                  Adjusted odds ratio*            Crude odds ratio             Adjusted odds ratio*            Crude odds ratio
Exclusively breast fed for:
  <2 months (n=2084)                               0.89 (0.73 to 1.07)           0.87 (0.74 to 1.02)            0.90 (0.65 to 1.24)          0.84 (0.64 to 1.10)
  3-5 months (n=2052)                              0.87 (0.72 to 1.05)           0.64 (0.53 to 0.76)            0.65 (0.44 to 0.95)          0.50 (0.36 to 0.69)
  6-12 months (n=863)                              0.67 (0.49 to 0.91)           0.51 (0.38 to 0.67)            0.57 (0.33 to 0.99)          0.38 (0.22 to 0.64)
  >12 months (n=121)                               0.43 (0.17 to 1.07)           0.36 (0.16 to 0.82)            0.28 (0.04 to 2.04)          0.18 (0.03 to 1.28)
Ever breast fed (n=5184)                           0.79 (0.68 to 0.93)           0.70 (0.61 to 0.80)            0.75 (0.57 to 0.98)          0.61 (0.50 to 0.76)
*Odds ratios adjusted for level of parental education, maternal smoking during pregnancy, low birth weight, own bedroom, and frequent consumption of butter.



BMJ VOLUME 319            17 JULY 1999    www.bmj.com                                                                                                                 149
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                                                                                              Contributors: RvK coordinated and designed the study, ana-
                                                                 Key messages             lysed the data, wrote the paper and is guarantor for the paper.
                                                                                          BK had the original idea for the study and wrote the nutritional
 + Obesity is the most frequent nutritional disorder in children, and is                  aspects of the discussion. TS contributed to the discussion of the
   an important risk factor for cardiovascular disease in adulthood                       results. EvM designed the questionnaire for the study of atopy
                                                                                          and made important suggestions about the epidemiological and
 + Preventing obesity in children should be a useful strategy in                          statistical analyses and the writing of the paper. DB managed the
   preventing later heart disease because weight loss interventions in                    dataset on all children enrolled in the 1997 school entry health
   obese children are costly and rarely successful                                        examination. VG checked all statistical procedures and calcula-
                                                                                          tions in SAS, and is also a guarantor for the study. HvV initiated
 + Data from a cross sectional study in Bavaria suggest that the risk of                  the research project in collaboration with the public health
   obesity in children at the time of school entry can be reduced by                      offices in Bavaria.
   breast feeding: a 35% reduction occurs if children are breastfed for                       Funding: Bayrisches Staatsministrium für Arbeit und Sozial-
   3 to 5 months                                                                          ordnung, Familie, Frauen und Gesundheit and Stiftung
                                                                                          Kindergesundheit.
 + Preventing obesity and its consequences may be an important                                Competing interests: None declared.
   argument in the drive to encourage breast feeding in industrialised
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                  is more likely to be related to the composition of breast                    comment]. Am J Clin Nutr 1996;64:663-4.
                                                                                          22   Deheeger M, Akrout M, Bellisle F, Rossignol C, Rolland-Cachera MF.
                  milk than to lifestyle factors associated with breast                        Individual patterns of food intake development in children: a 10 months
                  feeding. Preventing childhood obesity and its conse-                         to 8 years of age follow-up study of nutrition and growth. Physiol Behav
                                                                                               1996;59:403-7.
                  quences may be an important argument in the drive to                    23   Burns SP, Desai M, Cohen RD, Hales CN, Iles RA, Germain JP, et al. Glu-
                  encourage breast feeding in industrialised countries.                        coneogenesis, glucose handling, and structural changes in livers of the
                                                                                               adult offspring of rats partially deprived of protein during pregnancy and
                  We thank all parents for answering the questionnaires, the doc-              lactation. J Clin Invest 1997;100:1768-74.
                                                                                          24   Desai M, Byrne CD, Zhang J, Petry CJ, Lucas A, Hales CN. Programming
                  tors and their assistants in the public health offices for distribut-        of hepatic insulin-sensitive enzymes in offspring of rat dams fed a
                  ing and collecting the questionnaires, for encouraging the                   protein-restricted diet. Am J Physiol 1997;272:G1083-90.
                  parents to answer the questionnaires and for measuring and              25   Desai M, Hales CN. Role of fetal and infant growth in programming
                  recording the weight and height of all children attending the                metabolism in later life. Biol Rev Camb Philos Soc 1997;72:329-48.
                  school entrance health examination                                           (Accepted 4 May 1999)


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